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Reports


Inspection carried out on 10 July 2018

During a routine inspection

The inspection took place on 10 and 18 June and was unannounced.

At our last planned comprehensive inspection in September 2017, we found concerns and took enforcement action. We carried out a focused inspection in November 2017 to check on whether improvements had been made. At that inspection, we rated the service was rated Requires Improvement in the Safe and Well led key questions. There were no breaches of regulation but we could not rate the service further from requires improvement because to do so requires consistent good practice over time. At this inspection, we found that improvements had been made and the service is now rated as Good in all of the key questions, and Good overall.

Beech Hall is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Beech Hall is registered to provide accommodation for up to 64 people requiring nursing or personal care. Beech Hall is purpose built and is located in the Armley area of Leeds. At the time of our inspection there were 51 people using the service.

There is a registered manager in post but they were not present at the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.'

At our last comprehensive inspection, we made a recommendation that the provider review their training for staff in relation to the delivery of meaningful activities for people living with Dementia. At this inspection, we found staff had completed further dementia awareness training at level two and aimed to provide an in-depth understanding of dementia and how it affected people using the service.

Medicines were managed safely. Staff were knowledgeable and received training around the management and administration of medicines. There were good relations with local healthcare services and the service utilised the contacts for advice. For example, phoning the district nurses to discuss changes in people's needs and to ensure they received timely advice to address these concerns.

People told us they felt safe. We saw that there were pro-active measures in place to monitor people's safety, such as observation charts and analysis of falls data to identify and address risks. There were risk assessments in place where needs had been identified, for example when a person was at risk of falling.

Care staff understood their responsibilities with identifying abuse and reporting safeguarding concerns.

There were enough staff to meet people's needs. The provider calculated staffing levels in line with people's care needs.

The provider had a safe system for the recruitment of staff and appropriate checks were conducted prior to staff starting work, to ensure their suitability for the role. There were sufficient staff on duty to keep people safe and meet their needs,

The home was clean and free from odours throughout. Maintenance checks were completed on the building and equipment, with any areas for repair addressed promptly.

Staff received an induction which included training to help them carry out their roles effectively. Training was updated regularly and staff had their competency checked in relation to the management of medicines. Staff received regular supervision and appraisal of their work performance.

Care plans were written using person centred details, care staff referred to these for guidance and updated them regularly in the event of a person's needs or preferences changing. Records were well documented and there was clear involvement with health professionals in a timely manner when assessed and required. People were

Inspection carried out on 20 November 2017

During an inspection to make sure that the improvements required had been made

We carried out an unannounced comprehensive inspection of this service in September and October 2017. Three breaches of legal requirements were found. These were regulation 12, safe care and treatment, regulation18, staffing and regulation 17, good governance. We issued a notice of decision to impose conditions on the providers registration, but specific to this location.

We undertook this focused inspection to check the required improvements had been made and to confirm that the location now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Beech Hall on our website at www.cqc.org.uk

Beech Hall is registered to provide accommodation for up to 64 people requiring nursing or personal care. Beech Hall is purpose built and is located in the Armley area of Leeds. At the time of our inspection there were 58 people living at the home.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had made improvements to the ensure safety checks of the environment and equipment were completed in a timely manner. Also they had ensured that where actions were identified these were carried out. However, we found that further improvements were required in relation to record keeping.

People told us they felt safe and staff were clear about their responsibilities in relation to protecting people from avoidable harm or abuse. Records showed that risks were identified and managed safely. Accidents and incidents were dealt with appropriately and monitored by the provider.

There were safe medicine management systems in place.

The provider carried out appropriate background checks before employing staff, and we found they were deployed in sufficient numbers to provide care and support safely.

The majority of people and staff we spoke with were complimentary about the registered manager and management team. However, we did receive some feedback about areas that could improve.

Inspection carried out on 19 September 2017

During a routine inspection

This inspection took place on 19, 20 September and 2 October 2017 and was unannounced. This was the first inspection we have carried out at this location since a change to their registration in May 2017.

Beech Hall is registered to provide accommodation for up to 64 people requiring nursing or personal care. Beech Hall is purpose built and is located in the Armley area of Leeds. Accommodation is over three floors. The top floor can accommodate up to 25 people, the middle floor 23 people and the ground floor up to 16 people. Each floor has single bedrooms which have en-suite facilities. There are communal bathrooms throughout the home. Each floor has an open plan communal lounge and dining room. The home has a lift to access all floors and has car parking to the front of the building. There is a selection of communal rooms throughout the building.

At the time of this inspection the home had a registered manager who had been in post since February 2017. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Before the inspection we received a notification of an incident at Beech Hall that occured prior to the current provider’s registration. Following the incident a service user sustained a serious injury. The incident is subject to a criminal investigation and as a result of these considerations, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management and safety of equipment and staffing levels. This inspection examined those risks.

We identified a number of concerns relating to fire safety. This included daily fire safety checks not being carried out, failure to maintain equipment and insufficient staffing levels. Following our inspection we contacted the fire service and they visited the home.

We found that essential health and safety checks of equipment used to assist people had not been carried out. This put people at risk of harm.

The home did not employ staff for the purpose of organising and facilitating activities for people. The registered manager told us this was the responsibility of care staff. Our observations were that people living at the home were not provided with the opportunity to engage in meaningful activities. We recommend that the provider reviews their training for staff in relation to the delivery of meaningful activities for people living with Dementia.

We looked at the home’s medication policy and found it was robust and gave staff guidance on how to administer people’s medication safely and appropriately. Records we looked at were accurate, medication rooms were clean and tidy and temperatures of both the room and the medication fridges were monitored and recorded.

Recruitment practices were safe and thorough. Staff demonstrated a good understanding of how to protect vulnerable adults. They told us they had attended safeguarding training. Policies and procedures were in place to make sure any unsafe practice was identified and people living at the home were protected. People living at the home told us they felt safe and knew how to report concerns about their safety if they had any.

During our visit we saw people looked well cared for. We observed staff speaking in a caring and respectful manner to people who lived in the home. Staff demonstrated that they knew people’s individual characters, likes and dislikes. People's nutritional needs were met and they had access to a range of health care professionals to maintain their health and well-being.

Care plans were person centred and individually tailored to meet people’s needs. We looked in people’s bedrooms and found people had personalised th